Elissa Ladd’s career as a nurse practitioner has run parallel to the nursing field’s entry into the prescribing world.  Ladd, who holds nursing degrees from the University of Pennsylvania and Rush University and a doctorate in health policy and nursing from the University of Massachusetts, is now an assistant clinical professor of nursing at the Massachusetts General Hospital Institute of Health Professions.  She recently received a $400,000 grant from the Attorney General Consumer and Prescriber Grant Program to create an education program to teach advanced practice nurses about pharmaceutical companies’ influence on prescribing.  

Ladd talked with PostScript about her time in the classroom and the exam room, and how she’s seen pharma pay increasing attention to nurse prescribers in both. 

PS: How does the pharmaceutical industry interact with the nursing profession? Does it differ from industry interaction with physicians?

EL: Throughout my career, I’ve watched the evolution of prescribing influence on nursing grow.  When I first started practicing as a nurse practitioners, most NPs across the country didn’t have the statutory authority to prescribe yet—we would be practicing, and we’d get scripts from physicians.  About 20 years ago, NPs began to gain prescriptive authority on a state by state basis.

PS: So how wide does nurse prescribing power extend?

EL: Nurse practitioners can now prescribe in all 50 states, as can a group of advanced practice nurses (APNs), which includes psychiatric nurse specialists/clinicians, nurse anesthetists and nurse-midwives.  And that whole group of APNs who prescribe – 150,000—is comparable to the number of family practice physicians practicing in the U.S. today. So we are a sizable force, and Pharma has begun to recognize that.

For the last decade, it’s been interesting to watch the drug company influence grow.  Drug detailers are heavily, heavily targeting NPs now.  It’s the same thing as physicians — annual meetings, continuing education.  And even though there’s been a lot written in the press, I think it’s going to be a developmental process for our profession, because we haven’t had prescribing authority as long as doctors have. Advance practice nurses are now getting  a lot of attention from pharma, and they are enjoying the recognition in a sense, but it’s, you know, perverse. 

PS: In the course of your training and career, when did you become aware of the relationship between the drug industry and the medical profession?  Was industry present in nursing school? 

EL: Well, there wasn’t any pharmaceutical influence during my training at nursing school.  We took pharmacology, but that’s about it.  We didn’t have prescriptive authority, and though it was understood to be just a matter of time and regulation, industry influence was never an issue.  The same is true today: they really haven’t injected themselves into NP training and nursing school, and Im not sure the reason for this – it could be now that pharma influence in medical schools is being scrutinized more closely.

PS: In your view, what is the most worrisome part of the pharmaceutical industry’s relationship with prescribers?

EL: Continuing Education. Absolutely.

PS: Why?

EL: CE is required in order to maintain your nursing license and nurse practitioner certification, just as CME is for physicians, and many times the ones that are free are offered by pharma—and that means pharma provides the speakers.  There’s clearly a conflict of interest operating in this system, and people are really naïve about that.  They can get CE credits and go to these sponsored luncheons.  The problem is that most people think it’s educational, but the programs are really biased.  It’s a veiled process of marketing that people don’t acknowledge or understand, but it’s clearly marketing, nonetheless.  I just think a lot of people aren’t even at the point of acknowledging it.  But both nurses and physicians are very influenced by industry-funded continuing education programs.

PS: Are there alternatives?

EL: Yes, you can find industry-free CE programs, but you have to go looking.  The thing that concerns me is that a lot of the industry-free content  is for CME, not CE, which is what nurses need to get recertified.  I know there are some NIH ones.  But I’d say overall it’s probably less available for nurses than physicians. 

PS: You’ve written that there is a dearth of literature about pharmaceutical influence on your profession—have we missed an opportunity by not paying enough attention to industry relations with nurses?

EL: As I said, nurses are still a bit naïve about this whole thing, since prescribing is a relatively new aspect of the profession.  Physicians are naïve, too, but also in denial.  Oh, it doesn’t influence me, you hear them say.  But of course, pharmaceutical companies aren’t stupid, and they wouldn’t be spending billions unless it influenced practices.  So they know, but they don’t want to know. 

PS: From your vantage as a professor and clinician, do you see this relationship between industry and medicine changing?

EL: I do think there is a tremendous momentum around this.  I think that there’s not only an individual awareness, but policy-wide awareness is growing, too.  Academic Medical Centers are leaders in terms of practice issues, and I think changes there will really trickle down into smaller practices and hospitals, and filter into the NP community as well.  Whether people like it or not, I think the culture is changing. 

PS: A recent survey by the Center for Congressional and Presidential Studies at American University reported that 82 percent of Americans trust the FDA to oversee medication approval, 67 percent trust drugmakers, and 53 percent trust Congress.

In your opinion, how much unrealized public outrage is out there to be harnessed?  And is public outrage—grassroots anger—necessary to move this issue?  Whom must we convince?

EL: There have been some interesting studies that have asked patients: “Do you know your doc takes gifts from pharmaceutical reps?”  It’s funny because most of the patients didn’t know that, and they are angry once they find out.  I see a shift happening at the physician and medical center level.  But once consumers become more aware, I think there will be even a larger shift.

The Attorney General Consumer and Prescriber Grant Program [of which Ladd is a recipient] will be awarding a grant to a consumer education project on these issues in the coming months, which I think will help patients  become more involved in this issue, too, the way they did with antibiotics.

PS: A shift in antibiotics?

EL: Once the public learned that about bacterial resistance – from their doctors and the CDC guidelines issued in 2001 about antibiotic overuse – we saw a lot of awareness, a big decrease in prescribing, especially among pediatricians.  It was a significant shift.  That’s an example where the docs, especially pediatricians, have done a very good job of changing their own culture. 

PS: What has been your most memorable experience with pharmaceutical reps or marketing? How did it change the way you practice or prescribe?

EL: It was a couple of years ago and I was working at a family practice, with two docs.  I had never seen so much drug paraphernalia—it was plastered all over the place, down to the paper on the exam table.  It was like the Nexium ad or something.  He couldn’t even buy his own exam paper?  I mean, that’s pretty in-your-face.  I’ve actually seen it on toilet paper, too.

And this practice was getting free lunches every day.  Every day!  And you listen to a talk while you eat.  You don’t really think about it initially.  But one day, I did start thinking: Wait a second, they’re doing this every day, and I just didn’t feel right about it. So I decided I wasn’t going to go to the next lunch.  One of the docs passed me on his way there. 

“Don’t you want to get some lunch?”  I said no, I was just going to stay and work on my charts.  Then there was this silence, probably ten seconds.  “It doesn’t affect what I prescribe,” he said.  “I just go in there and eat their food.”

But ultimately, it’s the patients that pay for those meals, in the form of higher cost drugs.  It was a cascading clarity that I got about this issue.  It’s all unconscious, that name recognition.  It works for drugs, for cars, for washing machines.  It works for refrigerators.  It just works.

The amazing thing to me is that we know this happens.  We know.  They wouldn’t be spending what they spend if they weren’t getting some return.